December 6, 1997
Chris Green, Jakarta, Indonesia
again we must thank Prof. Frerichs for raising an important concern.
We have long identified perceived risk to medical staff as a significant
potential cause of discrimination towards PWAs. In Indonesia
at least, medical staff including doctors are poorly informed
about the risks of infection by AIDS and the easy way out is to
avoid treating people infected by HIV. Nurses and hospital administrative
staff often demonstrate their fear to the dismay of patients
as Sally Smith from Nepal has pointed out, we gain little by testing.
What is primarily needed, as is so often the case when irrational
fear must be addressed, is education. In one hospital here in
Jakarta, I discussed this point with the nursing manager. She recalled
that when the first case of AIDS was admitted in the early '90s,
many of the staff were unwilling to approach the patient. She then
started a program of education, not only of the nurses but also the
administrative, cleaning and catering staff, to ensure that they were
aware of the methods by which HIV is (and is not) transmitted, and
the relatively simple rules of Universal Precautions which will prevent
that transmission (and that of other equally dangerous and much
more easily transmitted infections) in a hospital setting. She also
prepared a clear procedure to be followed in case of needlestick or
other potential injuries. The result is that this hospital is still
the most welcoming for AIDS patients. Further, to my knowledge
no potentially infecting injuries have occurred there.
as far as I am aware, few hospitals in Indonesia have emulated
them. General knowledge of Universal Precautions is limited.
know of no publication in Indonesian language (or perhaps more importantly,
in cartoon form, as has been prepared in Australia), which
describes Universal Precautions and their relevance to AIDS and other
infectious diseases. Similarly provision for disposal of 'sharps'
appears to be haphazard at best. And I doubt more than a handful
of hospitals (if that) have a procedure for needlestick injuries.
is to these requirements that attention must be given, rather than the illusive solution of universal
testing, which besides being impractical
and causing a false sense of security, will almost certainly
be administered with little concern for the rights of the patient.
I would be interested to hear how these challenges have been addressed
in countries where the epidemic is more mature.
December 6, 1997
Lalit M. Nath, India
note that the same arguments in favour of testing are still being put forward, regardless of the fact that no one is
against appropriate testing!! Incidentally,
India does have an official policy on testing, the
document is available from NACO.
there not a report of someone who was tested, diagnosed and counseled in
New York or New Jersey -- and went on to willfully infect several girls.
December 9, 1997
Karla Meursing, Australia
benefits of early detection of HIV infection depend on the context testing is done in. Indiscriminate
calls for early testing can cause damage.
agree it would be worthwhile to make sure that voluntary testing is available, provided it is accompanied by
counselling and long-term support options.
However, in many context the "voluntary" character of testing can become
clouded with direct and indirect pressure on a person to 'choose' for
the HIV test. For example, in hospital patients are often eager to please their doctor and this may be their main
reason to agree to an HIV test,
rather than the desire to know their HIV status.
addition, the effect of testing (voluntary or otherwise) depends on what action the infected person takes after the
test result is known. Positive action
- such as using condoms, informing one's partner, and planning for the future - presupposes the infected person
actually has the power, the resources,
and the information to translate knowledge into action.
we have learnt anything from years and
years of HIV education, it is that "telling
people (of the risks of HIV, or of their HIV status) is NOT enough to effect behavior change." Thus, simply
being told one's HIV status is not enough
to effect protection of others, nor to achieve improvement in the predicament
of the seropositive person him/herself.
order to achieve these ends, the person
with HIV should have access to adequate treatment and
to family planning and condoms. He/she should also actually have the social power to use family planning and
condoms; have access to information,
and social and material support; and to legal and other effective
protection, should his/her environment react with discrimination and
many countries in the world, these conditions are not met. Thus,
issues of prevention (by early detection for instance) and of support and care are intimately linked, and the issue
of testing should be always be
considered in conjunction with the issue of support and protection available to those infected. If there is very
little, or no help available for
people with HIV, public interest in voluntary testing is likely to be low, and people who find out they have HIV may
well feel so helpless they decide
to hide their HIV status and continue to live as others do - which may include unprotected sexual intercourse.
an in-depth discussion and many illustrations of what it means to be HIV positive in a society where fear of HIV
has resulted in severe stigma, and
where poverty limits the options of people with HIV to cope with their diagnosis, I refer to my book: A World of
Silence - Living with HIV in Matabeleland,
Zimbabwe (1997 Royal Tropical institute Amsterdam).
Burnet Centre for Medical Research
Vic 3078, AUSTRALIA